1. Medical Home Program Care, Compassion, Community

2. Westside Healthcare is a busy Family and Pediatric practice in Franklin, NH An LRGHealthcare-owned facility, Westside Healthcare provides care for patients from newborns to the elderly. Patients can choose Franklin Regional Hospital (FRH) in Franklin, Lakes Region General Hospital (LRGH) in Laconia, or a number of other nearby facilities for laboratory, radiological, and specialty needs.

3. Westside Healthcare Providers Paul Friend, MD ~ Family Practice Melissa Hanrahan, MD ~ Family Practice Joanne Goodrich, APRN ~ Family Practice Danielle MacDonald, APRN ~ Family Practice Jo-Ann Lopez-Valles, MD ~ Pediatrics Mark Weinreb, MD ~ Pediatrics

4. What’s making a difference at Westside?

5. Reporting We are currently tracking: – Diabetic patients with an A1C over 9%, a Blood Pressure of 140/90 or above, and those who haven’t been seen in 6 months – Hemoccult cards that were issued but not yet returned

6. Recall Letters Recall letters are sent to our diabetic patients if, after reviewing the chart, it is determined that the patient: – does not have an appointment scheduled here to follow up – is not followed by a specialist – has not responded to a request by the provider for an appointment – Patients are receiving the letters we are mailing out, and they are responding!

7. 6-month Recall Letter

8. High A1C Letter

9. High Blood Pressure Letter

10. Hemoccult Card Letter

11. Test and Referral Completion A monthly Orders Status report is generated through our EMR, ensuring that all tests and referrals placed by each provider are reviewed and completed in a timely manner. Chart review ensures that: – Any requested test has a report in the chart and/or the referral has a consult note. If we do not have results/consult notes, we follow up with the office to which the patient was referred. If the patient did not go to the appointment, the referring provider is notified and the referral or test is cancelled.

12. ER Use We review our patients’ use of the ER each day. – Slips from the ER inform us when one of our patients was treated in the ER. – The report in the EMR is reviewed to see if the visit was emergent, or if the issue could have been handled in our office. – If the patient was seen for a non-emergent reason, and did not call us first, we send a letter to remind them to first try to use the office setting whenever possible, instead of the ER, for both quality and cost reasons.

13. Diabetes Flowsheet

14. Heart Stroke Flowsheet

15. Preventative Healthcare Launcher - female

16. Preventative Healthcare Launcher - Male

17. Health Coach Melissa Rizzo, Franklin Regional Hospital Community Health Educator, will be at Westside one morning and one afternoon per month to meet with our patients one-on-one to help them with topics such as: – Smoking Cessation – Weight Loss – Exercise – The 5-2-1-0 program

18. Mental Health Dr. James Gulla, of Genesis Behavioral Health, provides short term counseling services for our patients at Westside on Wednesdays. Our providers make the referral, and the staff at Genesis call the patient to schedule the appointment with them directly.

19. Franklin Regional Hospital Rehab Services Beginning in February 2010, Franklin Regional Hospital Rehab Services will be located on the Westside Campus. Services will include Physical and Occupational Therapy, as well as therapeutic massage.

20. Challenges Restructuring of work flows with limited staffing. Improving understanding among the staff of the changes necessary to effectively implement the Medical Home Model of Care. Creation and automation of user friendly reports. Effective and efficient process that minimizes staff time.

21. Our Wish List Master reports for each targeted disease to encompass all items being reported upon and the mailing list for that month. To effectively educate our patients upon their role in the Medical Home Model of Care. To improve oral health in our community. To offer Group Education classes to our patients.

22. How has this changed Westside? This project has strengthened our commitment to provide quality patient centered care. We continue to identify community healthcare needs, assist in setting goals, and aid patients in lifestyle changes necessary to improve all aspects of their health. Employees have been given the opportunity, to face new professional challenges, allowing them to work outside their traditional job roles.

23. What Comes Next? Heart Stroke Disease Management Targeted measures include:  Blood Pressure Control – less than 140/90  Complete Lipid Profile - Annually  Cholesterol - less than 100  Aspirin or other antithrombotic therapy  Smoking status